Online Submissions: http://www.wjgnet.
com/esps/ World J Gastrointest Surg 2013 April 27; 5(4): 110-114
wjgs@wjgnet.com
doi:10.4240/wjgs.v5.i4.110
Efficacy of subcutaneous penrose drains for surgical site
infections in colorectal surgery
Shinya Imada, Shingo Noura, Masayuki Ohue, Tatsushi Shingai, Toshinori Sueda, Kentaro Kishi,
Terumasa Yamada, Hiroaki Ohigashi, Masahiko Yano, Osamu Ishikawa
Shinya Imada, Shingo Noura, Masayuki Ohue, Tatsushi
Shingai, Toshinori Sueda, Kentaro Kishi, Terumasa Yamada,
Hiroaki Ohigashi, Masahiko Yano, Osamu Ishikawa, Depart-
ment of Surgery, Osaka Medical Center for Cancer and Cardio-
vascular Diseases, Osaka 537-8511, Japan
Author contributions: Imada S designed the review, collected
the data, and drafted the manuscript; all authors approved the fi-
nal manuscript.
Supported by Osaka Medical Center for Cancer and Cardiovas-
cular Diseases
Correspondence to: Shingo Noura, MD, PhD, Department
of Surgery, Osaka Medical Center for Cancer and Cardiovas-
cular Diseases, 1-3-3 Nakamichi, Higashinariku Osaka, Osaka
537-8511, Japan. noura-si@mc.pref.osaka.jp
Telephone: +81-6-69721181 Fax: +81-6-69728055
Received: July 24, 2012 Revised: January 14, 2013
Accepted: March 15, 2013
Published online: April 27, 2013
Abstract
AIM: To investigate whether a subcutaneous penrose
drain would decrease the superficial surgical site infec-
tion (s-SSI) rate in elective colorectal surgery.
METHODS: This is a comparative study of the his-
torical control type. Intervention consisted of the use
of penrose drain in elective open colorectal surgical
wounds. The outcome was an incidence of s-SSI. The
patients were risk stratified according to the depth of
subcutaneous tissue.
RESULTS: There were 131 patients (40 patients with
high s-SSI risk) in the prior period (from July 2008 to
June 2009, when no penrose drains were inserted) and
151 patients (75 patients with high s-SSI risk) in the
latter period (from June 2010 to November 2011, when
penrose drains were inserted). The overall s-SSI rate
was 6.1% and 5.3% during the two periods (P = 0.770),
and the s-SSI rate in the high s-SSI risk group was
WJGS|www.wjgnet.com
ISSN 1948-9366 (online)
© 2013 Baishideng. All rights reserved.
BRIEF ARTICLE
15.0% and 8.0% (P = 0.242).
CONCLUSION: Although penrose drain was not ob-
served to significantly reduce s-SSI, there tended to be
a reduced risk of s-SSI in the high s-SSI risk group.
© 2013 Baishideng. All rights reserved.
Key words: Surgical site infections; Subcutaneous pen-
rose drains; Colorectal surgery; Open surgery; Subcu-
taneous tissue
Core tip: In this article, the authors investigated wheth-
er a subcutaneous penrose drain would decrease the
superficial surgical site infection rate in elective colorec-
tal surgery. Although penrose drain were not observed
to significantly reduce superficial surgical site infection,
there tended to be a reduced risk of superficial surgical
site infection in the high superficial surgical site infec-
tion risk group(depth of subcutaneous tissue was over
20 mm).
Imada S, Noura S, Ohue M, Shingai T, Sueda T, Kishi K, Yamada
T, Ohigashi H, Yano M, Ishikawa O. Efficacy of subcutaneous
penrose drains for surgical site infections in colorectal surgery.
World J Gastrointest Surg 2013; 5(4): 110-114 Available from:
URL: http://www.wjgnet.com/1948-9366/full/v5/i4/110.htm
DOI: http://dx.doi.org/10.4240/wjgs.v5.i4.110
INTRODUCTION
Surgical site infections (SSI) are still a major problem in
general surgery, because they are responsible for signifi-
cant discomfort for patients and excess morbidity and
mortality, which also translates into a financial burden on
the health system[1]. Superficial SSI (s-SSI) account for
about 60% of SSI, and the occurrence is associated with
wound separation, ventral hernia, and so on[2].
110 April 27, 2013|Volume 5|Issue 4|

Figure 1 Depth of subcutaneous tissue at the level of the umbilicus.
SSI surveillance by an infection control team (ICT)
started in September 2003 at this hospital. The incidence
of s-SSI in colorectal surgery decreased from 12% to
about 5% by the intervention of the ICT[3]. However,
s-SSI still occurs at a low rate yet, and we therefore need
further interventions to decrease the incidence of s-SSI.
One consideration is to remove the blood and serous
fluids from the wound by drains before fluids can get
infected[4]. This concept is frequently implemented in
clinics. However, a meta-analysis showed that prophy-
lactic subcutaneous drainage to prevent wound com-
plications is not efficient in gynecology[5]. On the other
hand, there have so far been few reports on the efficacy
of prophylactic subcutaneous drain for the prevention
of s-SSI following digestive surgery. Recently one study
described a systematic randomized evaluation in patients
undergoing laparotomy in digestive surgery while clarify-
ing whether subcutaneous closed suction drains affect
wound infection, and the authors concluded that there
were no indications for prophylactic subcutaneous suc-
tion drain[4]. Furthermore, there is no evidence about the
use of prophylactic subcutaneous penrose drains (PD)
which are likely to be used more widely than suction
drains in digestive surgery due to the fact that they are
cheaper. Moreover, there is no evidence about the effect
of PD following elective colorectal surgery, in which the
incidence of s-SSI is usually higher than other fields.
This study analyzed the efficacy of PD for the pre-
vention of s-SSI in elective colorectal surgery.
MATERIALS AND METHODS
This study was a prospective cohort with historic con-
trols in order to assess the use of PD. Patients undergo-
ing elective open colorectal surgery were included in this
study. Patients who underwent emergency surgery, lapa-
roscopic surgery, and re-do operations were excluded.
The study classified two periods, the prior period and
the latter period. The prior period was from July 2008 to
June 2009, in which no PD was inserted subcutaneously
in patients that underwent elective colorectal surgery. The
latter period was from June 2010 to November 2011,
WJGS|www.wjgnet.com
Imada S et al . Efficacy of subcutaneous penrose drains
and PDs (an open drain, 8 mm; Fuji Systems Corpora-
tion, Japan) were inserted subcutaneously in patients
that underwent elective colorectal surgery for prevention
of s-SSI. The data of the prior period were collected
retrospectively from the medical records, and PDs were
prospectively inserted in cases that met the eligibility cri-
teria during the latter period. Moreover, the patients from
each period were divided into two groups, the low s-SSI
risk group and the high s-SSI risk group. The two groups
were based on whether the depth of subcutaneous tissue
was over 20 mm, because Soper et al[6] reported that the
depth of subcutaneous tissue is the most significant risk
factor associated abdominal wound infection after hyster-
ectomy. The depth of subcutaneous tissue was measured
preoperatively at the level of the umbilicus based on ab-
dominal computed tomography (Figure 1).
Every patient received the same preparations, that
is, sennoside and magnesium citrate were administered
following fasting 1 d before surgery and followed by a
glycerin enema in the morning of the day of surgery.
No patient underwent chemical bowel preparation. The
patients took showers 1 d before surgery, and underwent
body hair removal just before the operation. Moreover,
the surgical field was disinfected by the use of iodine
and the patients received antibiotic prophylaxis with ce-
fmetazole just before the initial skin incision, every 3 h
during the operation, and twice per day on the first and
second postoperative days.
The skin incision was performed with a scalpel; sub-
cutaneous fat was dissected by electrocautery. Wound
protection was achieved during the operation by a ring
drape device. The surgical instruments were exchanged
just before the peritoneal-muscle closure, and the wound
was irrigated with 1000 mL of saline solution just be-
fore skin closure. The fascia/muscle layer was closed by
interrupted VICRYL® sutures (Ethicon, Somerville, NJ,
United States) and the skin was closed by stapling. There
were no differences in the surgical procedures between
the latter an prior period, except that a PD was inserted
along the entire length of the subcutaneous tissue. The
exit of the drain was separated from the incisions. The
PD was removed on postoperative day three.
SSI cases were diagnosed within 30 postoperative day
by ICT according to the Centers for Disease Control and
Prevention (CDC) criteria: (1) purulent drainage with or
without laboratory confirmation from the superficial inci-
sion; (2) organisms isolated from an aseptically obtained
culture of fluid or tissue from the superficial incision; (3)
at least one of the following signs or symptoms of infec-
tion: Pain or tenderness, localized swelling, redness, or
heat and superficial incision were deliberately opened by
surgeon, unless the incision was culture-negative; and (4)
diagnosis of s-SSI by the surgeon or ICT.
Statistical analysis
Numerical data are given as the mean ± SD, and they
conformed to the normal distribution. Discrete data were
tested for significance by means of the χ2 test or Fisher’s
exact test. Continuous data were tested for significance with
111 April 27, 2013|Volume 5|Issue 4|
 Imada S et al . Efficacy of subcutaneous penrose drains
Table 1 Demographic characteristics of the patients in the two periods
Prior period (n = 131)
Age (yr, mean ± SD) 62.7 ± 10.4
Sex (male/female) 68/63
Diabetes mellitus (yes/no) 17/114
Smoking history (yes/no) 24/107
ASA classification (ASA score ≤ 2/3 ≤) 124/7
Body mass index (kg/m2) 22.4 ± 3.3
Subcutaneous fat (mm, mean ± SD) 18.2 ± 7.8
Site (colon/rectum) 73/58
Operation time (min, median) 206
Blood loss(mL, median) 205
Stoma (yes/no) 32/99
Patients with high risk1 40
Patiens with PD 0 151
1
High risk patients whose depth of subcutaneous tissue are over 20 mm. ASA: American Society of
Anesthesiologists; PD: Penrose drains.
Student’s t-test. P < 0.05 was considered to be significant.
RESULTS
One hundred thirty-one patients underwent surgery dur-
ing the prior period, and 151 patients during the latter
period. The PD was usually removed on postoperative
day 3, but the physician in charge removed it depend-
ing on properties and amount of drainage. The median
times of removal of PD were postoperative day three
(range 2-12). There were no severe complications associ-
ated with the insertion of the PD. The characteristics of
patients during the two periods are shown in Table 1.
There was no significant difference between the two pe-
riods with regard to the characteristics, such as age, sex,
diabetes mellitus, smoking history, American Society of
Anesthesiologists classification, body mass index, opera-
tion time, blood loss, and presence of stoma. However,
the proportion of high s-SSI patients was different be-
tween the two periods (30.5% vs 49.7%, P = 0.001). The
types of surgery of all of the patients and the high s-SSI
group patients are shown in Table 2, and there was no
significant difference between each group during the two
periods (overall P = 0.440, high risk group P = 0.190).
The characteristics of the high s-SSI risk patients in the
two periods are shown in Table 3. No significant differ-
ences were noted with regard to characteristics between
the two periods.
The incidences of s-SSI in the two periods are shown
in Table 4. The overall s-SSI rate was 6.1% (8/131) in the
prior period, and 5.3% (8/151) in the latter period. The
s-SSI rate in the high risk group during the two periods
was 15.0% and 8.0% (P = 0.242). The s-SSI rate was
reduced by half. However, there was no significant differ-
ence between two the periods. In contrast, the s-SSI rate
of the low risk group during the two periods was 2.2%
and 2.6% (P = 0.855). There was no significant difference
between the two periods. Moreover, 6 s-SSI cases of the
high risk group in the latter period are presented in Table
5. There were 4 culture-positive cases among in the latter
WJGS|www.wjgnet.com
Latter period (n = 151) P value
63.0 ± 12.4 0.847
91/60 0.158
20/131 0.947
32/119 0.547
146/5 0.399
22.5 ± 3.5 0.802
19.7 ± 7.1 0.081
95/56 0.220
219 0.864
200 0.169
31/120 0.433
75 0.001
period. Three of 4 cultures showed bacteria in the intes-
tines, and only one culture was skin bacteria.
DISCUSSION
SSI is one of the most serious infectious complications
of surgery. The occurrence is associated with a high
incidence of reoperation, a long duration of hospitaliza-
tion, and a large increase in the cost of any postoperative
surgery complication. In addition, patient discomfort and
the inconvenience of caring for a healing open wound at
home make the prevention of this complication a high
priority[6]. s-SSI has a high incidence among SSI, and it
is generally thought that the incidence of s-SSI is related
to amount of bacterium of the wound, formation of
hematoma, pool of effusion, potential subcutaneous
dead space, disturbance of the local circulation, and the
amount of bacterium in the surgical organ[7].
A subcutaneous drain might reduce the amount of
bacterium around the wound and remove residual ef-
fusion and blood from the wound that could serve as a
medium for bacterial growth. This study selected a PD,
which is an open drain, because of its convenience and
inexpensiveness. Generally, a PD or closed suction drain
is used as a subcutaneous drain. A closed drain is an ac-
tive drain that employs the power of suction. The luminal
obstruction of such drains increase with time, and drain-
age becomes poor 48 h after insertion[7]. On the other
hand, long term insertion of a PD is associated with
retrograde infection. Moro et al[8] pointed out that the
insertion of an opened drain for more than 3 d increases
the risk of SSI. In addition, Numata et al[9] reported that
25% of cultures of discharge from subcutaneous PDs
that was inserted over 3 d postoperatively, were positive
for skin bacteria. Therefore, the PD was removed on
postoperative day three. Table 5 shows the s-SSI cases
in the latter period. There were 5 culture positive cases
among the 8 s-SSI cases in the latter period. Four cultures
of the 5 cases showed bacteria in the intestines, and only
one culture was skin bacteria. Moreover, the cost of PD
112 April 27, 2013|Volume 5|Issue 4|
 Imada S et al . Efficacy of subcutaneous penrose drains

Table 2 Types of surgery during the two periods

Prior period (n = 131) Latter period (n = 151)

Overall High risk group Overall High risk group
Resection of the colon 73 18 95 46
Resection of the rectum with the stoma 31 10 28 16
Resection of the rectum without the stoma 27 12 28 13
Total 131 40 151 75

Table 3 Demographic characteristics of the high risk patients

Prior period (n = 40) Later period (n = 75) P value

Age (yr, mean ± SD) 61.8 ± 9.7 62.5 ± 11.0 0.743
Sex (male/female) 15/25 36/39 0.280
Diabetes mellitus (yes/no) 5/35 10/65 0.899
Smoking history (yes/no) 8/32 15/60 > 0.999
ASA classification (ASA score ≤ 2/3 ≤) 40/0 75/0 > 0.999
Body mass index (kg/m2) 24.2 24 0.767
Site (colon/rectum) 18/22 46/29 0.093
Operation time (min, median) 245 239 0.588
Blood loss (mL, median) 275 205 0.110
Stoma (yes/no) 9/31 18/57 0.857

ASA: American Society of Anesthesiologists.

Table 4 Incidence of superficial surgical site infections during the two periods n (%)

Prior period (n = 40) Later period (n = 75) P value

Patients with s-SSI (high s-SSI risk group) 6/40 (15.0) 6/75 (8.0) 0.242
Patients with s-SSI (low s-SSI risk group) 2/91 (2.2) 2/76 (2.6) 0.855
Patients with s-SSI (overall) 8/131 (6.1) 8/151 (5.3) 0.770

s-SSI: Superficial surgical site infections.

Table 5 Superficial surgical site infections cases in the later period

Case Age Sex ASA Fat tissue (mm) s-SSI risk Operation Daysof drainage Culture
1 72 M 2 23 High Resection of the rectum with the stoma 4 Not done
4 71 F 2 24 High Resection of the colon 4 Not detected
2 55 M 2 27 High Resection of the colon 3 Staphylococcus aureus (skin bacteria)
3 73 M 2 27 High Resection of the colon 3 Enterococcus facium (intestine bacteria)
5 56 F 2 22 High Resection of the rectum with the stoma 3 Pseudomonus aeruginosa (intestine bacteria)
6 81 F 2 21 High Resection of the colon 3 Bacteroides fragilis (intestine bacteria)
7 64 M 2 18 Low Resection of the colon 4 Enterococcus facium (intestine bacteria)
8 62 M 2 16 Low Resection of the colon 4 Not detected

ASA: American Society of Anesthesiologists; M: Male; F: Female; s-SSI: Superficial surgical site infections.

is less expensive than that of a closed drain. Each type of
drain has specific advantages and disadvantages.
Numata et al[7] reported that PD is an effective means
for preventing s-SSI in high s-SSI risk patients following
digestive tract surgery. However, they classified contami-
nated operations and dirty-infected operations, or clean-
contaminated operations accompanied by at least 20 mm
thick subcutaneous fat into the high s-SSI risk group, and
they reported that PD was more efficient in contaminat-
ed surgery, such as a perforation of the colon. However,
the cases in the current study were restricted to elective
colorectal surgeries, and the amount of bacteria was
found to be small. As a result, a potential risk of bias in
the intervention population may have existed. Moreover,
the current protocol exchanged the surgical instruments
just before peritoneal-muscle closure, and performed
wound irrigation with 1000 mL of saline solution just
before skin closure. So, the decrease of s-SSI has a pos-
sibility of limit from the aspect of drainage in elective
colorectal surgeries.

WJGS|www.wjgnet.com 113 April 27, 2013|Volume 5|Issue 4|

 Imada S et al . Efficacy of subcutaneous penrose drains
In regard to suture choice, we always closed the fas-
cia/muscle layer with VICRYL® sutures in clean-contam-
inated surgery. However, multifilament sutures, such as
VICRYL®, are more prone to develop SSI than monofila-
ment wire, such as PDS®. On the other hand, one recent
study reported that antibacterial-coated multifilament
(VICRYL PLUS®) was more effective than monofilament
(PDS-Ⅱ®)[10]. We therefore need to examine the suture
choice to prevent s-SSI from now on.
The current study failed to demonstrate the efficacy
of PD. However, dead space in the subcutaneous layer
is a risk factor of s-SSI, and Inotsume-Kojima et al[11] re-
ported that a combination of subcuticular sutures and a
drain for the skin closure reduces wound complications
in obese females undergoing surgery using vertical inci-
sions in gynecology. Furthermore, interventions associat-
ed with subcuticular sutures may be necessary in elective
colorectal surgery.
In conclusion, a PD was inserted subcutaneously to
reduce s-SSI following colorectal surgery. However, the
results failed to demonstrate that PD reduced the inci-
dence of s-SSI (6.1% vs 5.3%). Although the difference
was not significant, there was a trend toward a reduced
risk of s-SSI (15.0% vs 8.0%) in the high s-SSI risk group.
COMMENTS
COMMENTS
Background
Surgical site infections (s-SSI) are still a major problem in general surgery,
because they are responsible for significant discomfort for patients and excess
morbidity and mortality, which also translates into a financial burden on the
health system. The major parts of surgical site infections are superficial surgical
site infections, and it account for about 60% of surgical site infection.
Research frontiers
The incidence of superficial s-SSI is related to amount of bacterium of the
wound, formation of hematoma, pool of effusion, potential subcutaneous dead
space, disturbance of the local circulation, and the amount of bacterium in the
surgical organ. A subcutaneous drain might reduce the amount of bacterium
around the wound and remove residual effusion and blood from the wound that
could serve as a medium for bacterial growth. In this study, the authors inves-
tigate whether a subcutaneous penrose drain would decrease the superficial
surgical site infection rate in elective colorectal surgery.
Innovations and breakthroughs
Some surgeons use subcutaneous drains to prevent surgical site infection.
But there is no evidence of the efficacy of prophylactic subcutaneous drain for
the prevention of superficial surgical site infection following digestive surgery,
including colorectal surgery. This study analyzed the efficacy of penrose drains
for the prevention of s-SSI in elective colorectal surgery.
Applications
The current study failed to demonstrate the efficacy of penrose drains. But dead
space in the subcutaneous layer is a risk factor of s-SSI, and there are some
suture choices and some subcutaneous drains. So, the authors therefore need
to examine the combinations of suture and drain to prevent s-SSI.
Terminology
SSI is one of the most serious infectious complications of surgery. The occur-
WJGS|www.wjgnet.com
rence is associated with a high incidence of reoperation, a long duration of
hospitalization, and a large increase in the cost of any postoperative surgery
complication.
Peer review
This study compares a prospective cohort with historic controls in order to as-
sess the use of Penrose drains in median laparotomies in patients undergoing
colorectal resection in order to reduce superficial surgical site infections. It is a
retrospective case control study on a simple but important question.
REFERENCES
1 Romy S, Eisenring MC, Bettschart V, Petignat C, Francioli
P, Troillet N. Laparoscope use and surgical site infections
in digestive surgery. Ann Surg 2008; 247: 627-632 [PMID:
18362625]
2 Watanabe A, Kohnoe S, Shimabukuro R, Yamanaka T, Iso Y,
Baba H, Higashi H, Orita H, Emi Y, Takahashi I, Korenaga D,
Maehara Y. Risk factors associated with surgical site infec-
tion in upper and lower gastrointestinal surgery. Surg Today
2008; 38: 404-412 [PMID: 18560962]
3 Tanida T, Yamada T, Tanaka K, Tomimaru Y, Kishi K,
Noura S, Ohue M, Yano M, Ishikawa O, Imaoka S. Trial of
ICT intervention for the prevention of wound infection after
colorectal surgery. JJpanSocSurgInfect 2007; 4: 499-502
4 Baier PK, Glück NC, Baumgartner U, Adam U, Fischer A,
Hopt UT. Subcutaneous Redon drains do not reduce the
incidence of surgical site infections after laparotomy. A ran-
domized controlled trial on 200 patients. Int J Colorectal Dis
2010; 25: 639-643 [PMID: 20140620 DOI: 10.1007/s00384-010-
0884-Y]
5 Hellums EK, Lin MG, Ramsey PS. Prophylactic subcuta-
neous drainage for prevention of wound complications
after cesarean delivery--a metaanalysis. Am J Obstet Gy-
necol 2007; 197: 229-235 [PMID: 17826401 DOI: 10.1016/
j.ajog.2007.05.023]
6 Soper DE, Bump RC, Hurt WG. Wound infection after ab-
dominal hysterectomy: effect of the depth of subcutaneous
tissue. Am J Obstet Gynecol 1995; 173: 465-469; discussion
465-469 [PMID: 7645622 DOI: 10.1016/002-9378(9.5)90267-8]
7 Numata M, Tanabe H, Numata K, Suzuki Y, Tani K, Shi-
raishi R, Ooshima T, Rino Y, Imada T, Masuda M. The Ef-
ficacy of subcutaneous Penrose Drains for the Prevention of
Superficial Surgical Site Infections. Jpn J Gastroenterol Surg
2010; 43: 221-228
8 Moro ML, Carrieri MP, Tozzi AE, Lana S, Greco D. Risk
factors for surgical wound infections in clean surgery: a mul-
ticenter study. Italian PRINOS Study Group. Ann Ital Chir
1996; 67: 13-19 [PMID: 8712612]
9 Numata K, Tanabe H, Numata M. Asessment about dis-
charge from inserted subcutaneous Penrose Drain in gastro-
enterological surgery. JJpnSocSurg Infect 2011; 8: 291-294
10 Justinger C, Slotta JE, Schilling MK. Incisional hernia af-
ter abdominal closure with slowly absorbable versus fast
absorbable, antibacterial-coated sutures. Surgery 2012; 151:
398-403 [PMID: 22088813]
11 Inotsume-Kojima Y, Uchida T, Abe M, Doi T, Kanayama
N. A combination of subcuticular sutures and a drain
for skin closure reduces wound complications in obese
women undergoing surgery using vertical incisions. J Hosp
Infect 2011; 77: 162-165 [PMID: 20971528 DOI: 10.1016/
j.jhin.2010.07.16]
P- Reviewers Ragg JL, Siassi M, Teeuwen PHE
S- Editor Song XX L- Editor A E- Editor Lu YJ
114 April 27, 2013|Volume 5|Issue 4|